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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - to the ICU after becoming
hemodynamically unstable with hypotension and increasing
tachycardia
• Bedside … • Miscommunication may occur verbally, in written reports, or both. … Case
Reports in Orthopedics. 2013;2013(3):1-3. doi:10.1155/2013/401968.
5. … Pulmonary Embolism and Severe Asthma: Case Report and Literature Review. … The radiology report - Are we getting the message across?
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - Changing the "routine care" paradigm requires a cultural shift and a reorientation of thinking focused … POKE scores are discussed by the bedside nurse. … One of our leading theories has to do with presence at the bedside. … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … authors has any affiliation or financial involvement that conflicts with the material presented in this report
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psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - No one even understood what it was, how you recognized it at the bedside, what patients were vulnerable … All these little things happen on the night shift because it's when things are otherwise quieter. … have to do major room switches, if someone comes up VRE or MRSA positive, they often do them on night shift … Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S
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psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - deterioration before the outcome
became inevitable, a hospital-wide Early Warning System based on networked bedside … Readers should not interpret any statement in this report as an official position of AHRQ or
of the … authors has any affiliation or financial
involvement that conflicts with the material presented in this report
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - One trend that I hope we’ll sustain is the shift to rapid communities of learning across local, regional … We can’t simply legislate our way into putting more colleagues at the bedside as the determinant that … https://www.nursingworld.org/~4a209f/globalassets/covid19/anf-2022-workforce-written-report-final.pdf … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … authors has any affiliation or financial involvement that conflicts with the material presented in this report
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - The pandemic accelerated a shift from healthcare in the hospital toward healthcare in the home and … https://www.nursingworld.org/~4a209f/globalassets/covid19/anf-2022-workforce-written-report-final.pdf … We can’t simply legislate our way into putting more colleagues at the bedside as the determinant that … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … authors has any affiliation or financial involvement that conflicts with the material presented in this report
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psnet.ahrq.gov/web-mm/forgotten-turn
August 01, 2018 - patients, staff members place a SKIN ALERT sticker on the outside of the chart, along with signs at the bedside … repositioned at a minimum of every 2 hours.( 10 ) Cues for repositioning have included clocks at the bedside … Empowerment of the bedside nurse as the focal point for protecting patients along with strong support … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … May 1, 2004
Letter
In response to "Failure to Report
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - Her parents demanded transfer to a specialty hospital, but there was a shift change and the new emergency … A telehealth connection to bring the pediatric intensivist and transport team to the child’s bedside … The use of I-PASS for patient handoffs during inpatient pediatric shift changes was found to decrease … Family members report experiences of poor information sharing and little shared decision-making during … Brief report: the impact of maternal posttraumatic stress disorder symptoms and child gender on risk
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psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
April 26, 2023 - I need to go now to the patient’s bedside.” … traditional ICU levels, or even a more condition-specific level, you get thousands of alarms per nurse per shift … The engineer mapped the existing workflow of nurses at the bedside and thought about how the monitor … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … authors has any affiliation or financial involvement that conflicts with the material presented in this report
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psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - moment three different elevators arrived on the ground floor, more than 30 staff members (at their shift … the closest elevator, but this was a bay designated for staff—who were just leaving at the end of a shift … Clinical outcomes after bedside and interventional radiology paracentesis procedures. … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … , 2012
Process changes to increase compliance with the Universal Protocol for bedside
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psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
March 10, 2021 - Initiative PFE Measures
PfP PFE Measures:
Planning Checklist for Scheduled Admissions
Shift … it doesn't affect the bedside. … Or, how many times did they participate in bedside rounding during their stay? … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … authors has any affiliation or financial involvement that conflicts with the material presented in this report
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psnet.ahrq.gov/primer/medication-administration-errors
September 07, 2019 - Background Medication errors have been a key target for improving safety since Bates and colleagues' reports … documentation, and use of standardized administration practices such as dual nurse verification at the bedside … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … in Medication Safety September 7, 2019
Editor's Picks
An analysis of incident reports … March 15, 2017
Shift-to-shift handoff effects on patient safety and outcomes: a systematic
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psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - Her
parents demanded transfer to a specialty hospital, but there was a shift change and the new emergency … Second, the shift change introduced a new treating physician who did not recognize
the necessity of … A telehealth connection to bring the pediatric intensivist and transport team to the child’s
bedside … The
use of I-PASS for patient handoffs during inpatient pediatric shift changes was found to decrease … Brief report: the impact of maternal posttraumatic
stress disorder symptoms and child gender on risk
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - KH : I assume that it takes time to see the culture shift, over years. … EL : It’s a paradigm shift. … The paradigm shift about the value of who that person is in the bed is key. … But care at the bedside, and of course I am a little bit biased, is very good. … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S
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psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
August 31, 2020 - KH : I assume that it takes time to see the culture shift, over years. … EL : It’s a paradigm shift. … The paradigm shift about the value of who that person is in the bed is key. … But care at the bedside, and of course I am a little bit biased, is very good. … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S
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psnet.ahrq.gov/periodic-issue/periodic-issue-381
March 15, 2023 - issue highlights what's new this week in patient
safety literature, news, conferences, reports … This study reports on how trust and psychological safety interact to increase error reporting. … Thirty-one studies reported that long hours, shift work, overtime, and/or poor sleep quality contributed … The bedside and charge nurses had difficulty placing the NGT and the X-ray confirmation was not done. … and treating acute agitation secondary to delirium, and the importance of clear communication during shift
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - the intervention is that an RRT program brings individuals with critical care skills promptly to the bedside … Others report that standing by a deteriorating patient with no resources to help—in the absence of an … If a response is defined as a thorough bedside evaluation by a team member who possesses some critical … Speed and agility are values, which are to keep up with the industry, keep up with the needs, to shift … when we have to shift, and to change when we've done something wrong.
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psnet.ahrq.gov/web-mm/informed-or-misled
April 24, 2018 - The role of clinical guidelines in medical negligence litigation: a shift from the Bolam standard? … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … authors has any affiliation or financial involvement that conflicts with the material presented in this report … Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside
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psnet.ahrq.gov/node/49684/psn-pdf
May 01, 2013 - In the morning his bedside nurse for the day came in
and stated that she would be giving him his fourth … A national trend, in place for more
than a decade, has resulted in a shift in the setting in which chemotherapy … The shift of oncology inpatient care to outpatient care: the challenge of retaining expert
oncology … Readers should not interpret any statement in this report as an official position of AHRQ or
of the … www.ncbi.nlm.nih.gov/pubmed/20616197
involvement that conflicts with the material presented in this report
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psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
September 07, 2019 - Physician reviewers evaluated parents' reports and designated incidents as errors or quality issues or … The study team's clinician review panel assessed patient concerns and shared reports deemed to be safety … About one quarter of patient feedback reports were considered safety concerns, and more than half resulted … clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside … communication, integrating patients and families into shift changes, and using patient input to improve